Cost savings and health losses from reducing inappropriate admissions to a department of internal medicine.

OBJECTIVES: Inappropriate hospital admissions are commonly believed to represent a potential for significant cost reductions. However, this presumes that these patients can be identified before the hospital stay. The present study aimed to investigate to what extent this is possible. METHODS: Consecutive admissions to a department of internal medicine were assessed by two expert panels. One panel predicted the appropriateness of the stays from the information available at admission, while final judgments of appropriateness were made after discharge by the other. RESULTS: The panels correctly classified 88% of the appropriate and 27% of the inappropriate admissions. If the elective admissions predicted to be inappropriate had been excluded, 9% of the costs would have been saved, and 5% of the gain in quality-adjusted life-years lost. The corresponding results for emergency admissions were 14% and 18%. CONCLUSIONS: The savings obtained by excluding admissions predicted to be inappropriate were small relative to the health losses. Programs for reducing inappropriate health care should not be implemented without investigating their effects on both health outcomes and costs.

The cost of inappropriate admissions: a study of health benefits and resource utilization in a department of internal medicine.

OBJECTIVES: High rates of inappropriate hospital admissions have been found in numerous studies, suggesting that a high percentage of hospital resources are, in effect, wasted. The degree to which this is true depends on how costly inappropriate admissions are compared to other admissions. This study aimed to estimate both the percentage and cost of inappropriate admissions. SETTING: Department of internal medicine at a teaching hospital. SUBJECTS: Consecutively admitted patients during a six-week study period. MAIN OUTCOME MEASURES: Assessments of inappropriateness were based on estimates of health benefit and necessary care level. These estimates were made by expert panels using a structured consensus method. Health benefit was estimated as gain in quality-adjusted life years, or degree of short-term improvement in quality of life during or shortly after the hospital stay. The direct costs to the hospital of each stay were estimated by allocating the costs of labour, 'hotel' and overhead according to length of stay and adding to this the cost of ancillary resources used by each individual patient. RESULTS: A total of 422 admissions were included. The 102 (24%) judged to be inappropriate had a lower mean cost (US$ 2532) than the other 320 (US$ 5800) (difference 3268; 95% confidence interval 1025-5511). The inappropriate admissions accounted for 12% of the total costs. CONCLUSIONS: Denying care for inappropriate admissions does not generate cost reductions of the same magnitude. Policy makers should be cautious in projecting the cost savings potential of excluding inappropriate admissions.

[Student education in a laboratory for general practice skills]. / Studentundervisning i allmennmedisinsk ferdighetslaboratorium.

Clinical skills, like questioning and examining a patient, are developed gradually throughout the years of medical training. Basic skills should be mastered on graduation, but the teaching of skills in most medical schools is not systematic. We evaluated a pilot teaching project in a general practice (GP) skills laboratory. Students were randomised to an intervention group and a control group. Teaching was performed in small groups of one GP instructor and six students and consisted of four weekly three-hour sessions. For the control group, teaching was delayed until after evaluation. Evaluation of practical skills and communication skills was made with the students in random order by GP evaluators who did not know about the randomisation procedure. Each skill was scored as satisfactory or not satisfactory for each of five procedural elements. 56 fourth-year medical students volunteered. Evaluation was performed for 19 (68%) students in the training group and 18 (64%) in the control group. The training group performed better on practical skills, average score 9.7 (95% confidence interval 7.4 to 12.1) vs. 5.5 (3.2 to 7.8), (p = 0.01). There was no significant difference for communication skills, 7.7 (5.6 to 9.8) vs. 6.7 (4.6 to 8.7). Teaching clinical skills in a general practice skills laboratory is feasible. Practical skills may improve rapidly, at least for short-time performance, while our brief teaching in communication skills was not proved to be effective.

Does admission to a department of internal medicine improve patients' quality of life?

OBJECTIVES: The Tromsø Medical Department Health Benefit Study was designed to estimate health gains from admissions to a department of internal medicine. We have previously reported that the hospital stays had no effect on the life expectancy of 61% of the patients. However, it has been claimed that modern medicine has a greater effect on quality of life (QoL) than on life expectancy. The aim of the present study was to investigate this issue by estimating gains in QoL for patients admitted to a department of internal medicine. DESIGN: The time trade-off method (TTO) was used for assessing QoL gain from consecutive admissions during a 6-week period. The assessments were made by one of two expert panels, each consisting of an internist, a surgeon and a general practitioner, on the basis of summaries of all relevant clinical information about the patients. Short-term improvements in QoL during the stay or shortly after discharge were scored on an ordinal scale. RESULTS: Of the admitted patients, 41% had gains in QoL measured with the TTO (mean gain = 0.06; 95% confidence interval = 0.05-0.07; n = 422), and eight of these had gains equal to or greater than 0.50. Another 40% had gains in health-related short-term QoL measured with the ordinal scale. In a multivariate linear regression analysis, emergency admissions, high age and the disease categories 'endocrinological diseases' and 'pneumonia and influenza', were associated with higher gain, and 'undiagnosed symptoms' and 'cerebrovascular diseases' with lower gain. CONCLUSIONS: As judged by the expert panels, the investigated department of internal medicine was effective in improving the QoL of 81% of the admitted patients. Whilst most of the patients achieved small gains, a minority had gains in QoL corresponding to the treatment of life-threatening diseases.

Improving pulmonary auscultation as a tool in the diagnosis of bronchial obstruction--results of an educational intervention.

OBJECTIVE: To study the effect of an educational intervention on general practitioners' (GPs') ability to diagnose bronchial obstruction after clinical examination. DESIGN: Based on physical chest examination 11 GPs assessed the degree of bronchial obstruction by estimating the patient's predicted forced expiratory volume in one second (FEV1%). Half way in the study the GPs were taught new knowledge on associations between lung sounds and bronchial airflow. The agreements between estimated and measured FEV1% predicted before and after this educational intervention were compared. SETTING: 11 GPs in five health centres in northern Norway took part. PATIENTS: 351 adult patients were included in phase 1, and 341 in phase 2. MAIN OUTCOME MEASURES: Estimated and measured FEV1% predicted were compared in subgroups of patients according to clinical findings in phase 1 and 2. The effect of the intervention on the doctors' weighting of various chest signs could thus be evaluated. Kappa agreement and correlation between estimated and measured FEV1% predicted in both phases were determined. RESULTS: The agreement between estimated and measured FEV1% predicted increased from Kw (weighted Kappa) = 0.33 in phase 1 to Kw = 0.43 in phase 2 (95% confidence interval 0.35-0.52). The GPs laid more relevant emphasis on rhonchi in their estimates after the educational intervention, while too much weight was laid on uncertain chest findings in phase 2. CONCLUSION: The study shows a potential for better use of physical chest examination in the diagnosis of bronchial obstruction.

Does admission to a medical department improve patient life expectancy?

Doubts about the effectiveness of medical care in improving patient health have been raised by epidemiological studies and by studies of geographical variation and inappropriate use of health care. To investigate this problem, the life expectancy gain (LEG) from consecutive admissions to a department of internal medicine during a six-week period was assessed by two expert panels, each consisting of an internist, a surgeon, and a general practitioner. The mean LEG for all admissions was 2.25 years (n = 422). Sixty-one percent had a LEG of 0.10 years or less, while 5% had a LEG of more than 9.98 years. In a probabilistic sensitivity analysis, the mean LEG remained greater than zero under assumptions of overestimated positive LEG and underestimated negative LEG. We conclude that the life expectancy of the majority of the patients was not influenced by the admission, but that a minority had substantial gains, resulting in a high overall mean LEG.

Assessing health benefit from hospitalization. Agreement between expert panels.

Agreement between two expert panels in assessing gain in life expectancy and quality of life from unselected stays in a department of internal medicine was investigated. Weighted kappa statistics of 0.45 for gain in life expectancy and 0.63 for gain in quality of life were found.

[Professional activities and retirement among Norwegian physicians aged 55 years and over]. / Yrkesaktivitet og pensjonering blant norske leger over 55 år.

In a study of professional activity and retirement among 2,117 Norwegian doctors, the mean age of retirement was 68.5 years. It was lower among the younger doctors in the study group (those 70-74 years of age compared to those 80-84 years), and among female doctors, psychiatrists and doctors with impaired health, but was higher among doctors in the primary health service. Under the current pension scheme, the preferred age of retirement among those still working was on average 67.3 years, but was 65.1 if early retirement would not involve a reduced pension. It was lower among the youngest doctors, females, doctors who were frequently on duty, doctors in the primary health service, surgeons and doctors with impaired health. A reduction in the mean retirement age from 67 to 65 years would mean 300 fewer working doctors (i.e. 2% of the work force) by year 2003. Retired doctors considered the present age limit (75 years) of the medical license to be too low, while working doctors accepted it.